By Hatim Jaber MD MPH JBCM PhD 30-10 -2017 Faculty of Medicine Introduction to Community Medicine Course (31505201) Primary Health Care-PHC الرعاية الصحية الاولية By Hatim Jaber MD MPH JBCM PhD 30-10 -2017

Presentation outline PHC in Jordan Introduction and Definitions Time Introduction and Definitions 08:15 to 08:25 Levels of health care 08:25 to 08:40 Principles of PHC 08:40 to 09:00 Elements of PHC 09:00 to 09:15 PHC in Jordan 09:15 to 09:30

Introduction to course 31505201 Course Content Week 1 Unit 1: Introduction to Health and Community Health Week 2 Unit 2 Nutrition and Nutrition Assessment and Diet    Week 3 Unit 2 (cont.) Nutrition and Nutrition Assessment and Diet   Week 4 Unit 2 (con..): Infant and Breast Milk Characteristics   Week 5 Unit 3: Public Health/Environmental Health   Week 6 Public Health/Environmental Health Week 7 Unit 5: Primary Health care Week 8 Unit 6: : Introduction to Epidemiology and health indicators Demography, Data and Biostatics Week 9 Midterm assessment (Exams.)15-11-2017 Week 10 Unit 8 Public Health Surveillance Week 11 Unit 9: Prevention and Control of Diseases Week 12 Unit 10: Health Education and Communication Week 13 Unit 11: Screening Week 14 Unit 12: Health Administration and healthcare management Week 15 Unit 13: Revision and Health Research Week 16 Final assessment (Exams.)

Week 7 Unit 5: Primary Health Care- PHC Principles and elements of PHC 30-10-2017 2. Maternal and Child Health- MCH 1-11-2017

Declaration of Alma-Ata International Conference on Primary Health Care, Alma-Ata, USSR, 6-12 September 1978 Primary Health Care (PHC) PHC is: Essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that community and the country can afford … (Alma-Ata, 1978)

HEALTH FOR ALL ATTAINMENT OF A LEVEL OF HEALTH THAT WILL ENABLE EVERY INDIVIDUAL LEAD A SOCIALLY AND ECONOMICALLY PRODUCTIVE LIFE

PHC Definition PHC is an essential health care that is a socially appropriate, universally accessible, scientifically sound first level care provided by a suitably trained workforce supported by integrated referral systems and in a way that gives priority to those most in need, maximises community and individual self-reliance and participation and involves collaboration with other sectors.

What is Primary Health Care? PHC is essential health care that is a socially appropriate, universally accessible, scientifically sound first level care provided by a suitably trained workforce supported by integrated referral systems and in a way that gives priority to those most in need, maximises community and individual self-reliance and participation and involves collaboration with other sectors. It includes the following: health promotion illness prevention care of the sick advocacy community development

Comprehensive primary health care Social justice and equity Community control Social change Manages factors that generate ill health Involves an approach to health care over a continuum from health promotion to illness treatment

Comprehensive primary health care Complete physical, mental and social wellbeing Addresses issues of equity and social justice Considers the impact of education, housing, food and income Acknowledges the value of community development Recognises the expertise of individuals over their own health Talbot and Verinder 2005

community depending upon: Primary Health Care  is different in each  community depending  upon:  Needs of the residents; Availability of health care providers; The communities geographic location; & Proximity to other health care services in the area.  

Models of primary health care Comprehensive Selective Medical model View of health Positive wellbeing Absence of disease Absence of Disease Locus of control over health Communities and individuals Health professionals Medical practitioners Major focus Health through equity and community development Health through medical interventions Disease eradication through medical interventions Health care providers Multidisciplinary teams Doctors plus other health professionals Doctors Strategies for health Multi-sectoral collaboration Medical interventions Rogers W. & Veale, B. (2000).

WHO and Primary Health Care PHC The ultimate goal of primary health care is better health for all. WHO has identified five key elements to achieving that goal: reducing exclusion and social disparities in health (universal coverage reforms); organizing health services around people's needs and expectations (service delivery reforms); integrating health into all sectors (public policy reforms); pursuing collaborative models of policy dialogue (leadership reforms); and increasing stakeholder participation.

WHO Strategies of PHC 1. Reducing excess mortality of poor marginalized populations: PHC must ensure access to health services for the most disadvantaged populations, and focus on interventions which will directly impact on the major causes of mortality, morbidity and disability for those populations. 2. Reducing the leading risk factors to human health: PHC, through its preventative and health promotion roles, must address those known risk factors, which are the major determinants of health outcomes for local populations.

WHO Strategies of PHC cont.. 3. Developing Sustainable Health Systems: PHC as a component of health systems must develop in ways, which are financially sustainable, supported by political leaders, and supported by the populations served. 4, Developing an enabling policy and institutional environment: PHC policy must be integrated with other policy domains, and play its part in the pursuit of wider social, economic, environmental and development policy.

Declaration of the Alma Ata Released in 1978 and consisted of ten fundamental principles for effective comprehensive primary health care service delivery Principles were in response to the broader community and social issues leading to poor population health

The Ottawa Charter Building healthy public policy Creating environments which support healthy living Strengthening community action Developing personal skills Reorientating health care The Ottawa Charter for Health Promotion was developed in 1986

Characteristics of Primary Health Care (a) Stresses prevention rather than cure. (b) Relies on home self-help, community participation and technology that the people find acceptable, appropriate and affordable. (c) Combines modern, scientific knowledge and feasible health technology with acceptable, effective traditional healing practices. (d) Should be shaped around the life patterns of the population. (e) Should both meet the needs of the local community and be an integral part of the national health care system. (f) Should be formulated and implemented with involvement of the local population.

To Summarize Primary care is an approach that: Focuses on the person not the disease, considers all determinants of health Integrates care when there is more than one problem Uses resources to narrow differences

The Basic Requirements for Sound PHC (the 8 A’s and the 3 C’s) Appropriateness Availability Adequacy Accessibility Acceptability Affordability Assessability Accountability Completeness Comprehensiveness Continuity

Appropriateness Whether the service is needed at all in relation to essential human needs, priorities and policies. The service has to be properly selected and carried out by trained personnel in the proper way. Adequacy The service proportionate to requirement. Sufficient volume of care to meet the need and demand of a community

Affordability The cost should be within the means and resources of the individual and the country. Accessibility Reachable, convenient services Geographic, economic, cultural accessibility

Acceptability Acceptability of care depends on a variety of factors, including satisfactory communication between health care providers and the patients, whether the patients trust this care, and whether the patients believe in the confidentiality and privacy of information shared with the providers.

Availability Availability of medical care means that care can be obtained whenever people need it. Assessability Assessability means that medical care can be readily evaluated. Accountability Accountability implies the feasibility of regular review of financial records by certified public accountants.

Completeness Completeness of care requires adequate attention to all aspects of a medical problem, including prevention, early detection, diagnosis, treatment, follow up measures, and rehabilitation. Comprehensiveness Comprehensiveness of care means that care is provided for all types of health problems. Continuity Continuity of care requires that the management of a patient’s care over time be coordinated among providers.

Defining primary health care Primary Health Care is not Primary care alone. Primary, secondary and tertiary are levels of care

Care of vulnerable groups Primary Health Care Curative services Preventive services Outpatient clinic (referral) General services Care of vulnerable groups Laboratory services Maternal & child health . Health education Dispensary Monitoring of environment School health services First aid and emergency services Prev.&control of endemic diseases Geriatric health services Occupational health services Health office services

Levels of Care Primary health care Secondary health care Tertiary health care

Levels of Health Care Preventive Primary Secondary Tertiary Restorative Continuing

Preventive and Primary Care Settings School health services Occupational health services Physicians’ offices Clinics Nursing centers

Secondary and Tertiary Care Settings Hospitals/medical centers Emergency departments Medical units Intensive care Psychiatric facilities Rural hospitals

Restorative Care Settings Home health care Rehabilitation centers Extended care facilities

Why PHC Primary health care The “first” level of contact between the individual and the health system. Essential health care (PHC) is provided. A majority of prevailing health problems can be satisfactorily managed. The closest to the people. Provided by the primary health centers.

Secondary health care Tertiary health care More complex problems are dealt with. Comprises curative services Provided by the district hospitals The 1st referral level Tertiary health care Offers super-specialist care Provided by regional/central level institution. Provide training programs

Primary Health Care

Core Activities for PHC There is a set of CORE ACTIVITIES, which were normally defined nationally or locally. According to the 1978 Declaration of Alma-Ata proposed that these activities should include: Education concerning prevailing health problems and the methods of preventing and controlling them Promotion of food supply and proper nutrition An adequate supply of safe water and basic sanitation Maternal and child health care, including family planning Immunization against the major infectious diseases Prevention and control of locally endemic diseases Appropriate treatment of common diseases and injuries Basic laboratory services and provision of essential drugs. Training of health guides, health workers and health assistants. Referral services

Elements of PHC Education concerning prevailing health problems and the methods of preventing and controlling them Promotion of food supply and proper nutrition Monitoring an adequate supply of safe water and basic sanitation Maternal and child health care, including family planning Immunization against the major infectious diseases

Elements of PHC (cont.) Prevention and control of locally endemic diseases Appropriate treatment of common diseases and injuries Basic laboratory services and provision of essential drugs. Training of health guides, health workers and health assistants. Referral services

Elements of PHC (cont.) Mental health Physical handicaps Health and social care of the elderly

Principles for PHC PHC based on the following principles : Social equity Nation-wide coverage Self-reliance Inter-sectoral coordination People’s involvement in the planning and implementation of health programs

Principles of PHC The 1978 Declaration of Alma-Ata proposed a set of PRINCIPLES for primary health care. PHC should: “Reflect and evolve from the economic conditions and socio-cultural and political characteristics of the country and its communities, and be based on the application of the relevant results of social, biomedical and health services research and public health experience” 2. “Address the main health problems in the community, providing promotive, preventive, curative and rehabilitative services accordingly”

3. “Involve, in addition to the health sector, all related sectors and aspects of national and community development, in particular agriculture, animal husbandry, food, industry, education, housing, public works, 4. “Promote maximum community and individual self-reliance and participation in the planning, organization, operation and control of primary health care, making fullest use of local, national and other available resources; and to this end develop through appropriate education the ability of communities to participate”

5. “Be sustained by integrated, functional and mutually-supportive referral systems, leading to the progressive improvement of comprehensive health care for all, and giving priority to those most in need” 6. “Rely, at local and referral levels, on health workers, including physicians, nurses, midwives, auxiliaries and community workers as applicable, as well as traditional practitioners as needed, suitably trained socially and technically to work as a health team and to respond to the expressed health needs of the community.”

The Four Pillars of Primary Health Care Community Participation Appropriate Technology Inter-Sectoral Coordination Equitable Distribution

Primary Health Care in Jordan Primary health care services are managed through a wide network of MoH primary health care centers (95 comprehensive health center, 375 primary health care centers and 205 health sub-center in 2013), in addition to providing maternal, childhood and dental health services (448 Motherhood and Childhood Center and 387 dental clinic). The Royal Medical Services is involved in providing primary health care services through field clinics and eight comprehensive medical centers. UNRWA also provides primary health care services through 24 medical clinics. The Jordanian Society for Family Planning and Protection provides services through 19 clinics. This is in addition to the contribution of the private sector in these services through hundreds of general medical clinics.

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